Mohamed Safaei D.O.B 17.06.

1978
Bldg 4, Group 108, Rehab City, New Cairo, Egypt

44 years old male known recurrent Glioblastoma grade IV

Condition started year 2014 when he stuck whilst running.

Present C/O
PostOp (September 2022) left sided weakness 4/5 upper and lower limbs, circumduction gate, affected
coordination movements. (refractory to steroids), deteriorated to 3/5 then left hemiplegia (flaccid).

Left facial nerve palsy (UMNL).

Tonic seizures (first one started 29.11.2022 lasted for 3 minutes).

Enuresis whilst asleep.

Sleeping most of the time.

Glascow coma scale 13 (obeys commands, responds to speech, confused)
Bed bound. Karnofsky performance scale 40.

Year 2014 Oligodendroglioma (WHO grade II)

MRI 03.08.2014
Parafalcine right high frontal intra-axial space occupying lesion 3.5x3x2.5 cm. No oedema.

Surgery 19.08.2014 Right posterior frontal craniotomy: Abnormal cortex was excised whilst awake.
(Cromwell Hospital, London)

PostOp MRI Excellent resection, abnormal signal at the posterior margin of the resection
cavity.

Pathology 08/2014 Oligodendroglioma (WHO grade II), IDH mutant (R132H), LOH 1p19q

No radiotherapy

No chemotherapy commenced.

Medications 08/2014 Phenytoin commenced then shortly changed to Lamotrigine 50mg od

for 6 months then it was stopped as he was seizure free.

Follow up MRI 09.09.2016

- Post surgical changes
- Stationary post treatment gliotic encephalomalacic changes

Follow up MRI every 6 months

Stationary course
Year 2018 (Malignant transformation) (Oligodendroglioma WHO grade III)
Follow up MRI 08.10.2018
Presence of enhancing disease in the previous right posterior frontal resection cavity, abnormal
enhancement in the right parietal lobe. (multifocal recurrent disease with transformation)

Surgery 09.10.2018 (Frontal lesion) (Cromwell Hospital, London)

- Right frontal craniotomy (coronal section), abnormal area was resected back to the motor strip
posteriorly.
- PostOp left hemiparesis, rapidly improved with residual co-ordination difficulty.

PostOp MRI
Good resection, abnormal signal at the posterior margin of the resection cavity.
Cystic and peripherally enhancing abnormality in the inferior parietal lobule (supramarginal gyrus).

MRI 30.10.2018
- The resection cavities in the high right superior frontal gyrus and right parietal lobe exhibit some
residual peripheral and solid enhancement (post-surgical changes).
- Nodular enhancement on the postero-superior margin of the right parietal resection cavity.

Surgery Oct.2018 (Parietal lesion) (Cromwell Hospital, London)

Pathology 19.10.2018 Frontal tumour specimen

Oligodendroglioma (Malignant transformation) IDH mutant (WHO grade III), ARTX preserved, TERT
promoter mutant(-228), 1p19q codeletions and MGMT methylation.

No pathology was done for the parietal lesion.

Medications
02/2018
Keppra (Levetiracetam) 500mg bd
(Lower back pins and needles referred to the left foot)

Chemotherapy
PCV started 03/2019 - ended 07/2019 due to allergy to Natulan (Procarbazine)
(skin erythema and more focal skin lesions)

Temozolamide started 07/2019 – cycles ended Feb 2020 (monthly courses) (9 doses)

Radiotherapy 12.2018 – 02.2019 (International medical center, Cairo)

IMRT
Right Parieto-temporal region
30 fractions over 6 weeks
Total dose 60Gy
Year 2021 (Converted to Glioblastoma grade IV)
Follow up MRI 29.04.2021
- Right frontal parafalcine lesion showing stationary appearance post therapeutic changes.
- Newly seen solid and cystic lesion recurrence in the right parieto-temporal region.

Surgery 19.05.2021 (Parietal lesion) (Cromwell Hospital, London)

Pathology 11.06.2021
Glioblastoma grade IV
IDH wildtype, TERT promoter mutant(-250), EGFR amplified and mutant, PTEN mutant, CDKN2A loss,
19q LOH, Methylated MGMT promoter (28%)
No NTRK1,2,3 fusions, No evidence of EGFR vIII

Follow up MRI 27.07.2021

- Regression of the operative bed parietal lesion.
- Regression of the perilesional oedema.
- Glioticmalacic change at the right frontal parafalcine area.

Chemotherapy
Lomustine 40mg started 06.2021 ended 07.2022 (recurrence of tumour)

Avastin (Bevacizumab) started 07.2021 ended 08.2022 (recurrence of tumour)

Medications
Keppra (Levetiracetam) 500mg bd
Oral Dexamethsone 6mg od

Year 2022 (Glioblastoma grade IV)

Follow up MRI 22.08.2022
- Stationary appearance of the right frontal lesion.
- Surgical bed signal alterations and enhancement of the right periventricular area with mild vasogenic
oedema and white matter post treatment leukoencephalopathy.

Surgery 20. 09.2022 (Parietal lesion) (German-Saudi Hospital, Cairo)

Pathology 20. 09.2022

Glioblastoma grade IV
IDH-1 (R132H)-clone H09 (-ve),
lack TP53 mutation,
markedly elevated Ki-67 proliferation index in around 40% in tumour areas
ARTX not done
Follow up MRI 18.10.2022
- Right sided shunt tube, tip in the right ventricle.
- Increase in size of the tumour lesion surrounded with more oedema, where both exert effacement
of the adjacent cortical sulci and compression of the lateral ventricle.

Follow up MRI 03.11.2022

Tempero-parietal operative bed showing newly developed area of abnormal signal intensity distorting
the parenchymal pattern.
Progressive course of moderate vasogenic oedema with mass effect.

November 2022
Foundation one molecular tests (failed due to no enough DNA in the specimen).

Physiotherapy
1 session daily for upper and lower limb muscles
1 session daily for swallowing.

Medications

IM
Dexamethasone 8mg bd

Oral
Keppra (Levetiracetam) 1000mg bd

Epanutin 100mg tds

Amiloride/Hydrochlorthiazide 5/50mg od

Esmooprazole 40mg od

Venalafaxine XR 75mg 0d

Picolax t.d.s

Tolterodine I tartarate 4mg od

Acetylcysteine Effervescence 200mg t.d.s

Selenium Ace (Vit A, C, E) od

Nebulizer
Ipratropium 500mcg od
Budesonide 1mg od